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Multiple occupancies shall be in accordance with 6.1.14. 19.1.3.1.

Multiple occupancies shall comply with the requirements of 6.1.14.1 and one of the following:
(1) Mixed occupancies - 6.1.14.3
(2) Separated occupancies - 6.1.14.4 6.1.14.1.1.

Mixed Occupancy. A multiple occupancy where the occupancies are intermingled. 6.1.14.2.2.

The building shall comply with the most restrictive requirements of the occupancies involved, unless separate safeguards are approved. 6.1.14.3.2.

Approved single-station smoke alarms, other than existing smoke alarms meeting the requirements of 26.3.4.5.3, shall be installed in accordance with 9.6.2.10 in every sleeping room. 26.3.4.5.1.

The facility failed to provide smoke detection in a sleeping room used by staff.

Observation determined two staff Sleeping Rooms on the lower level were not equipped with a smoke detector.

Failure to provide smoke detection in a staff sleeping room increases the risk for injury or death due to fire.

This deficiency affected two (2) of two (2) staff sleeping rooms in the facility.

The facility failed to ensure the fire resistance rating of occupancy separation walls.

Fire doors shall latch upon closure. 19.1.3.4.1, 6.1.14.4.1, 8.3.3.1, NFPA 80 6.1.4.3.1

Observation determined the double set of cross corridor fire doors in the 2-hour barrier separating the Clinic and the Hospital failed to self-close and latch.

Failure to ensure the fire resistance rating of occupancy separation walls as required increases the risk of death or injury due to fire.

The deficiency affected one (1) of one (1) occupancy separation barrier in the facility.

Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage, and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening Protectives, except as otherwise specified in this code. 8.3.3.1.

Fire-rated door assemblies shall be inspected and tested in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. 7.2.1.15.2

The facility failed to inspect and test fire rated door assemblies throughout the facility.

Review of documentation and interview with staff determined fire rated door assemblies had not been inspected in the past year.

Failure to inspect and test fire rated door assemblies increases the risk of injury or death due to fire.

The deficiency affected numerous fire rated door assemblies throughout the facility.

Testing of required emergency lighting systems shall be permitted to be conducted as follows:

1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds.
2) The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction.
3) Functional testing shall be conducted annually for a minimum of 1½ hours if the emergency lighting system is battery powered.
4) The emergency lighting equipment shall be fully operational for the duration of the tests.
5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
7.9.3.1.1

The facility failed to ensure the emergency lighting was in proper operating condition to provide 1½ hours of emergency illumination in the event of failure of normal lighting.

Review of records indicated the facility failed to conduct a 90-minute annual test of the emergency battery back-up light in the past year.

Failure to provide emergency lighting as required increases the risk of death or injury due to fire.

The deficiency affected all emergency battery back-up lights in the building.

Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. 19.3.2.1

The facility failed to ensure hazardous areas in fully sprinklered existing health care occupancies were separated from other spaces by smoke-resisting partitions and self-closing doors.

Observation determined The corridor door to the Elevator Equipment Room, also used to store combustible materials, failed to self-close and latch into the door frame.

Failure to ensure hazardous areas were separated from other spaces by smoke-resisting partitions increases the risk of death or injury due to fire.

The deficiency affected one (1) of numerous hazardous areas in the facility.

Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. Automatic wet chemical fire-extinguishing systems shall be installed in accordance with the terms of their listing, the manufacturer's instructions, and NFPA 17A, Standard for Wet Chemical Extinguishing Systems. 19.3.2.5.1, 9.2.3, NFPA 96 10.2.6(4).

The facility failed to inspect, test and maintain the wet chemical extinguishing system in the Kitchen in accordance with NFPA 17A, Standard for Wet Chemical Extinguishing Systems and NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations.

On a monthly basis, inspection shall be conducted in accordance with the manufacturer's listed installation and maintenance manual or the owner's manual.

At a minimum, this quick check or inspection shall include verification of the following:

(1) The extinguishing system is in its proper location.
(2) The manual actuators are unobstructed.
(3) The tamper indicators and seals are intact.
(4) The maintenance tag or certificate is in place.
(5) No obvious physical damage or condition exists that might prevent operation.
(6) The pressure gauge, if provided, shall be inspected physically or electronically to ensure it is in the operable range.
(7) The nozzle blowoff caps, where provided, are intact and undamaged.
(8) Neither the protected equipment nor the hazard has not been replaced, modified, or relocated.

If any deficiencies are found, appropriate corrective action shall be taken immediately.
Where the corrective action involves maintenance, it shall be conducted by a trained service technician.
Personnel making inspections shall keep records for those extinguishing systems that were found to require corrective actions.
At least monthly, the date the inspection is performed and the initials of the person performing the inspection shall be recorded.
The records shall be retained for the period between the semiannual maintenance inspections. NFPA 17A 7.2.1 through 7.2.6

Review of documentation and interview with staff determined the monthly inspections of the wet chemical extinguishing system in the Kitchen had not been completed during the past twelve months.

Failure to install, inspect, test and maintain the wet chemical extinguishing system in accordance with NFPA 96 and NFPA 17A increases the risk of injury or death due to fire.

This deficiency affected one (1) of one (1) wet chemical extinguishing system in the facility.

Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6. 19.3.4.1

A fire alarm system required for life safety shall be installed, tested and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code. 9.6.1.3

The facility failed to ensure the fire alarm system was maintained, inspected and tested in accordance with NFPA 72, National Fire Alarm Code.

Review of documentation determined:

1) No documentation was available indicating an annual inspection and testing has been done on the fire alarm system and all the components associated with the fire alarm system in the past 12 months.

2) No documentation was available indicating a load voltage test of the fire alarm system batteries has been done in the past year.

3) No documentation was available to determine a monthly test of the fire alarm system dialer has been tested.

Failure to install, test and maintain the fire alarm system in accordance with NFPA 72 increases the risk of death or injury due to fire.

The deficiency affected the complete fire alarm system, which serves the entire building.

In spaces served by air-handling systems, detectors shall not be located where airflow prevents operation of the detectors. Detectors should not be located in a direct airflow or closer than 36 in. from an air supply diffuser or return air opening. 19.3.4.5.1, 9.6.2.10.1.1, NFPA 72 17.7.4.1, A.17.7.4.1

The facility failed to ensure the smoke detection system was in compliance with NFPA 72, National Fire Alarm and Signaling Code.

Observation determined one (1) smoke detector in the corridor near Radiology was installed within 36 in. of an air diffuser.

Failure to install the smoke detection system as required increases the risk of death or injury due to fire.

This deficiency affected one (1) of numerous smoke detectors in the facility. The smoke detection system serves the entire facility.

Automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. The property owner or designated representative shall correct or repair deficiencies or impairments that are found during the inspection, test, and maintenance required by NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems. 19.7.6, 4.6.12, NFPA 25 4.1.4.1

The facility failed to ensure the automatic sprinkler system was continuously maintained in a reliable operating condition as required by NFPA 25.

1) Record review and observation determined quarterly flow tests of the automatic sprinkler system were not completed as required. Records did not indicate a flow test was conducted during the first quarter of 2023, and the third and fourth quarter of 2022.

2) No record was available indicating weekly visual inspection of the automatic sprinkler system gauges and control valves has been completed.

Failure to inspect, test and maintain the automatic sprinkler system in accordance with NFPA 25 increases the risk of death or injury due to fire.

The deficiency affected the complete automatic sprinkler system, which serves the entire facility.

Fire dampers shall be tested and inspected in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Each damper shall be tested and inspected 1 year after installation. The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years. All tests shall be completed in a safe manner by personnel wearing personal protective equipment. Full unobstructed access to the fire or combination fire/smoke damper shall be verified and corrected as required. If the damper is equipped with a fusible link, the link shall be removed for testing to ensure full closure and lock-in-place if so equipped. The operational test of the damper shall verify that there is no damper interference due to rusted, bent, misaligned, or damaged frame or blades, or defective hinges or other moving parts. The damper frame shall not be penetrated by any foreign objects that would affect fire damper operations. The damper shall not be blocked from closure in any way. The fusible link shall be reinstalled after testing is complete. If the link is damaged or painted, it shall be replaced with a link of the same size, temperature, and load rating. All inspections and testing shall be documented, indicating the location of the fire damper or combination fire/smoke damper, date of inspection, name of inspector, and deficiencies discovered. The documentation shall have a space to indicate when and how the deficiencies were corrected. All documentation shall be maintained and made available for review by the AHJ. 19.5, NFPA 80, 19.4

The facility failed to test and inspect fire dampers as required by NFPA 80.

Record review and interview of staff determined the most recent inspection and testing of the fire dampers was done by an outside company on 12/04/2014, over 6 years ago.

Failure to maintain fire dampers in accordance with NFPA 80 increases the risk of death or injury due to fire.

This deficiency affected all fire dampers in the facility.

The facility failed to conduct fire drills as required.

Documentation was not available to determine fire drills were conducted on any shifts during the past year.

Failure to conduct fire drills as required increases the risk of death or injury due to fire.

The deficiency affected twelve (12) of twelve (12) drills in the past year.